Provider Demographics
NPI:1689054819
Name:MIZENER, BRUCE MARTY (BA)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:MARTY
Last Name:MIZENER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 20TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-3310
Mailing Address - Country:US
Mailing Address - Phone:727-710-2934
Mailing Address - Fax:
Practice Address - Street 1:3491 GANDY BLVD N STE 201
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2654
Practice Address - Country:US
Practice Address - Phone:727-547-0607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker